HIPAA Acknowledgment

• I understand that Pacific Sleep Program / Gerald B. Rich M.D. PC. will use and disclose health information about me.
• I understand that my health information may include information both created and received by this practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.
• I understand and agree that Pacific Sleep Program may use and disclose my health information to:
  • Make decisions about and plan for my care and treatment.
  • Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment.
  • Determine my eligibility for health plan or insurance coverage and submit bills, claims, and other related information to insurance companies or others who may be responsible for paying for some or all my health care.
  • Perform various office, administrative and business functions that support my physicians /health care providers’ efforts to provide me with, arrange and be reimbursed for health care and associated supplies and equipment.
• I understand that I have the right to receive and review a written description of how Pacific Sleep Program will handle health information about me. This written description is known as Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff, and other office personnel of Pacific Sleep Program, and my rights regarding my health information.
• I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices.
• I understand that I have the right to ask that some or all my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that Pacific Sleep Program is not required by law to agree to such requests.

Special Protections for Substance Use Disorder (SUD) Records:

• Some of your health information may be protected by federal laws and regulations that provide additional privacy protections for records related to substance use disorder (SUD) treatment (42 CFR Part 2). These SUD records receive greater protection than other health information.

How SUD Records May Be Used and Disclosed:

• In general, we may not use or disclose SUD records for treatment, payment, or health care operations without your written consent, except as permitted or required by law.
• When you provide a valid written consent, it may allow future uses and disclosures of your SUD records consistent with federal law.
• Redisclosure: SUD records disclosed under a valid consent may be redisclosed by HIPAA‑regulated entities in accordance with HIPAA, except as prohibited by law.

Legal Proceedings:

• SUD records (and testimony about them) will not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you provide written consent or a court issues an order after you are given notice and an opportunity to be heard.

Your Rights Regarding SUD Records:

• Request restrictions on certain uses and disclosures of your SUD records.
• Receive an accounting of certain disclosures of your SUD records.
• File a complaint if you believe your SUD privacy rights have been violated.

Our Duties:

• We are required by law to maintain the privacy of your SUD records and to notify you following a breach of unsecured SUD records.

Marketing Communications:

• We will not use or disclose your health information for marketing purposes without your written authorization, unless communication is permitted by law. If we send marketing communications that require authorization, you may revoke that authorization at any time in writing.

No Sale of Health Information:

• We do not sell your health information without your written authorization.

Fundraising Communications:

We may contact you for fundraising purposes. The information we may use includes limited details such as your name, contact information, dates of service, and department of service, as permitted by law.

• You have the right to opt out of receiving fundraising communications at any time, and doing so will not affect your treatment or payment for services.
• Each fundraising communication will include a clear and simple way to opt out.

Additional Protection for SUD Records

• SUD records will not be used for fundraising purposes without your written consent.
• If SUD records are ever used for fundraising as permitted by law, you will be given a clear and conspicuous opportunity to opt out before such use.